Skincare By Stavroula

Skincare By Stavroula

Client Consultation Form
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Ok to email?

YesNo
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact
Name
Emergency Contact Number
Please enter a valid phone number.
Your Skin Goals and Concerns:
How would you describe your skin type?

NormalComboOilySensitiveDryMild AcneModerate AcneMaturing & Aging
What Skin products are you using?
What Makeup products are you using?
Does your job and/or lifestyle require you to spend long periods of time outdoors?

YesNo
Do you wax your facial skin on a regular basis?

YesNo
If yes, approximately when was the last time?
Within the last month, have you had a facial, chemical peel, microdermabrasion, or any resurfacing treatments?

YesNo
If yes, which one:
example: Chemical Peel
Are you using Retin- A?

YesNo
Are you using Benzoyl Peroxide?

YesNo
Do you have any allergies or sensitivities to any of the following? If yes, please select all that apply

CosmeticLatexFragranceAlpha Hydroxy AcidsSunscreenPollenMedicine Iodine (Shellfish)Food/ Fruit/ Animal
If yes or other, please explain
Do you have any of the following health conditions? Please select all that apply

EczemaArthritisPsoriasisHysterectomyCold SoresPregnantThyroidLactatingDiabetesPlanning to become PregnantHormonal ImbalancesCancerHigh Blood PressureChemotherapyCirculatory IssueRecent SurgeryOther
If other, please explain
Do you take any medications? Please list
example: Accutane, Birth Control, Antibiotics
Anything else you would like to mention in regards to any skincare concerns or target goals?
I have read and completed this questionnaire truthfully and to the best of my ability. The treatments that I receive are voluntary and I release the company and/or skin care professional from any liability. All infromation is kept strictly confidential and is used only by your aesthetician for your service.
Today's Date*

MonthDayYear
Date
Signature*

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